A global perspective of advanced practice nursing research: A review of systematic reviews

Introduction The World Health Organization (WHO) called for the expansion of all nursing roles, including advanced practice nurses (APNs), nurse practitioners (NPs) and clinical nurse specialists (CNSs). A clearer understanding of the impact of these roles will inform global priorities for advanced practice nursing education, research, and policy. Objective To identify gaps in advanced practice nursing research globally. Materials and methods A review of systematic reviews was conducted. We searched CINAHL, Embase, Global Health, Healthstar, PubMed, Medline, Cochrane Library, DARE, Joanna Briggs Institute EBP, and Web of Science from January 2011 onwards, with no restrictions on jurisdiction or language. Grey literature and hand searches of reference lists were undertaken. Review quality was assessed using the Critical Appraisal Skills Program (CASP). Study selection, data extraction and CASP assessments were done independently by two reviewers. We extracted study characteristics, country and outcome data. Data were summarized using narrative synthesis. Results We screened 5840 articles and retained 117 systematic reviews, representing 38 countries. Most CASP criteria were met. However, study selection by two reviewers was done inconsistently and language and geographical restrictions were applied. We found highly consistent evidence that APN, NP and CNS care was equal or superior to the comparator (e.g., physicians) for 29 indicator categories across a wide range of clinical settings, patient populations and acuity levels. Mixed findings were noted for quality of life, consultations, costs, emergency room visits, and health care service delivery where some studies favoured the control groups. No indicator consistently favoured the control group. There is emerging research related to Artificial Intelligence (AI). Conclusion There is a large body of advanced practice nursing research globally, but several WHO regions are underrepresented. Identified research gaps include AI, interprofessional team functioning, workload, and patients and families as partners in healthcare. PROSPERO registration number CRD42021278532.


NP Primary care
Loescher (2018) [72] Decreased the number of unnecessary referrals to dermatologists in 2/2 studies NP Primary care Lovink (2017) [34] In LTC: Unplanned consultations for acute conditions increased sig. in intervention group, 3.0 vs 1.2 per year (P <0.0001), 1/1 study NP Primary care Swan (2015) [51] Number of referrals (3 studies) Two/ 3 investigated the number of specialty care visits; both found no differences between APNs and physicians.

NP Primary Care
Van Vliet (2020) [53] Referral (1 study) PAs refer 50% of their patients to another health care professional (e.g., a GP or an emergency department (ED)) while nurses referred 73% (p value not reported).Consultation (1 study) PAs consulted other health care professionals (e.g., a GP, an emergency physician, or a medical specialist) significantly more often compared to nurses (p value not reported).

NP Primary care
Yang (2021) [54] Referral pattern (1 study) 1.8 times higher odds of physician referral in states with full practice authority versus those in restricted practice states.
CNS Acute Kilpatrick (2014)* [55] CNSs in alternative provider roles were assessed in four studies with equal to statistically significant improvements in outcomes related to asthma management (e.g., attendance of ER follow-up visits and at 12 months, fewer asthma related ER visits).For patients with type 1 or 2 diabetes, CNSs had significantly more consultations (i.e.patient visits) and consultation times were longer.No significant differences in health care consultations (at most low-quality evidence).CNSs used significantly more resources because they made more referrals to mental health specialists and intervention patients had more general medicine and mental health clinic visits.

NP Primary Care
Donald ( 2015)* (transition) [33] Number of rehabilitation patient-to-staff consultation calls (p < 0.05): significant reduction Duration of rehabilitation patient-to-staff consultation calls (p < 0.05): significant reduction Total number of consultation calls: Rehabilitation 1 versus 7 calls p < 0.05; reported 1/1 Total duration of consultation calls: Rehabilitation 5 versus 48.5 min p < 0.05; reported 1/1 NP Primary Care Martin-Misener (2015)* [69] Consultation times (3 studies) Nurse practitioners had longer consultation times than general practitioners.3/3studies Meta-analysis of two studies with over 2500 patients, the mean total consultation time in the nurse practitioner group was 4.1 min longer per patient (95% CI 3.7 to 4.5; p<0.0001).Heterogeneity was high (I2=97%).Nurse practitioner consultations were significantly longer in 8 of 10 practices; the ratio of general practitioner to nurse practitioner consultation times varied from 0.57 (95% CI 0.49 to 0.67) to 0.92 (95% CI 0.7 to 1.21). 1 study Number of patients who were referred: Nurse practitioner and general practitioner care were equivalent.Non sig.

Costs (40 reviews) Care
Abraham (2019) [131] Costs for Laboratory, Diagnostics Procedures, or Medications (Table 2): T he cost for requested lab tests was significantly lower (-$44.06;p=0.001) in the APN group in one study).Costs of cardiovascular disease care provided by APNs compared to physicians for adult patients with atrial fibrillation and found the costs for blood tests and diagnostic procedures such as remote cardiac monitoring (Holter monitoring) and echocardiograms were higher by $41.36, $9.80, and $0.32, respectively in the APN group compared to the physician group in another study.Costs for diagnostic procedures such as stress tests, chest x-rays, and electrocardiography were lower by $2.13, $2.39, and $21.83, respectively in the APN group.Three studies reported lower medication costs in patients cared for by APNs compared to patients cared for by physicians.The average cost per adult patient per month for hypoglycemic medications, antihypertensive medications, and cholesterol-lowering medications prescribed to patients with type 2 diabetes mellitus was $21.03 lower in the APN group compared to the physician group, although the difference was not statistically significant researchers from the United Kingdom compared differences in cost for ulcer-healing medications provided to 175 patients by either APNs or physicians in an outpatient clinic (Chan et al., 2009).The mean cost per patient per week for these medications was $86.93 less for patients treated by APNs compared to physicians (p<0.001)(Chan et al., 2009).The total mean cost for cardiovascular medications (acenocoumarol, amiodarone, Ascal, beta-blockers, digoxin, fenprocoumon, sotalol, and verapamil) was $64.97 lower in the APN group compared to the physician group.
Costs for Patient Care Visits (Table 3): differences in costs for clinic, telephone, and emergency visit consultations were lower by $10.55, $6.79, and $7.92, respectively, for patients cared for by the APN compared to the physician.In a randomized controlled trial involving 181 patients with rheumatoid arthritis, the average cost per patient for clinic consultations in the United Kingdom was $62.20 less in the APN group compared to the physician group.The mean costs for outpatient facilities was $5,469 (p<0.05) less for patients receiving exclusive diabetes care from 1,536 APNs compared to 78,030 physicians (Lutfiyya et al., 2016).• After stratifying the sample by age (<65 years), the mean consultation cost (facility resources, follow-up, length of consultations, and salary) was $13.30 less (p<0.001) for patients cared for by APNs (Dierick-van Daele et al., 2010).• two randomized controlled trials comparing differences in costs of urinary incontinence care found physicians to be cost-effective by $385.30 in the Netherlands (Albers-Heitner et al., 2012) and $362.82 in the United Kingdom (Williams et al., 2005).Savings of $178.39 for primary care consultations in a sample of patients with diabetes in the APN group, but a loss of $81.39 and $332.27 for consultations to specialists and for outpatient facilities, respectively

APN Primary Care
Chan (2018) [42] Economic outcomes: Costs were examined in five studies with no significant changes noted in four studies.One/5 study reported higher costs for inpatient care (favour the control group).

APN Acute
Allsop (2021) [10]  Cost-efficiency: Statistically significant reductions in costs noted in one study and statistically significant increase in program costs favouring the control group noted after 12 months in one study.

APN Acute AND Primary
Bohner (2012) [98] Costs were examined in three studies with reductions in hospital costs, intervention costs, and costs per patients noted in all studies.In 1/3 studies, additional home visits did not offset overall cost savings APN Acute Edkins (2014) [91] Patients managed by the acute care NPs were hospitalized 2306 fewer days than the baseline population cared for by fellows, resulting in an overall $2,467,328 cost savings.When compared to other units, the Burn ICU evidences the lowest provider costs per year ($495,835) and per patient day ($66).These costs in light of the highest utilization (97.5%) among all of University of North Carolina 's ICUs reflect a unit that has high potential for provider burnout in 1/1 study NP Primary care Fichadiya (2021) [57] Comparison of cost of NP vs MD led HF care no significant differences in one study

APN Acute AND Primary
Hyde (2020) [115] Direct care cost: A total of three studies examined direct care costs with no difference noted in the three studies.

APN Acute
Joseph (2015) [106] Cost-effectiveness of endoscopy procedures performed by nurse endoscopists/nurse practitioners compared to medical endoscopists was examined in 2 studies with reduced costs in 2/2 studies APN Primary Care Kennedy (2012) [92] Reduction of costly health system issues found in 5 quantitative studies (ventilator days-; length of stays-; admission hospital rates-; A&E attendance-; number of appointments-, number of specialties attended.Improved cost effectiveness of clinic found in 1 qualitative study APN Primary Care Lawton (2018) [84] C ost-effective: Nurse-led care resulted in significantly higher costs per patient compared with doctor-led care, largely owing to differences in the number of hospital admissions and increased use of intravenous and nebulised antibiotics.Total cost of nurse-led care per patient in the first year was £5202, and total cost was £3262 in the second year.Costs of doctor-led care per patient in the first year were £2577 and in the second year £2851 APN Acute Manoj (2019) [63] Wait times and Costs were not reported in retained studies with APNs APN Acute Medeiros (2011) [94] Two of the NP studies found significant cost savings.APN Acute Monterosso (2019) [60] Nurse-led care: Two studies found cost reductions.Costs of nurse-led visits were significantly less than standard visits (€234 versus €503; p < 0.001).The average cost of nurse-led follow-up was lower than standard care (€2592 versus €3798; p = 0.11) even though more patients in the nurse-led group attended all five protocol visits (82% vs 60%; p = 0.002).Cost effectiveness assessed in 2 studies with statistically significant reductions noted in 2/2 studies Nurse-led telephone follow-up with group education was most costeffective for mean annual costs (€3 971, 95%CI, 2975-5186) and had the second highest mean quality-adjusted life years (0.772, 95%CI, 0.745-0.797;highest 0.776, 95%CI, 0.753-0.799) of the strategies tested.Significantly fewer patients who received the nursing intervention had one or more primary care visits (mean =2.75 (S.D. = 2.03) vs 3.59 (S.D. = 4.66)) during 6 months post-surgery found in one study.However, the related costs were not reported APN Acute Ordonez-Piedra (2021) [95] Cost effectiveness identified in seven studies with significant improvements noted in five studies of cost effectiveness.

CNS Acute
Salamanca-Balen (2018) [126] Equal to statistically significant reductions in costs in 40/46 studies with statistically significant increases in costs in 6/46 studies.
NP Acute Thamm (2019) [109] Cost effectiveness or utility Diverse findings noted in two studies including cost reductions primarily related to reduced salaries of NP and increased costs related to additional training for nurses that were incurred by the healthcare organizations.

APN Primary Care
Whiteford (2016) [111] Costs reported in two studies with reductions noted in 2/2 studies APN Acute Woo (2017) [96] Costs in critical care were reported in three studies with equal to reduced costs noted in 3/3 studies.

NP Primary Care
McMenamin (2023) [47] Costs measured in four studies with equal to statistically significant reductions noted in 4/4 studies for the intervention group.Although not significant, 1/4 study noted a trend toward higher costs in the intervention group related to long-term care and skilled nursing facility payments.

NP Primary Care
Fraser (2018) [132] Fees for service: Annual total savings if APRNs and physician assistants assume all the primary care visits in one state (Florida), total savings are estimated at $339 million Healthcare costs to organization: in the first 6 months of introducing an onsite nurse practitioner program.While the program cost $82,716, the organization realized $1.3 million in healthcare cost savings.Chenoweth and associates ( 2005) reported a benefit-to-cost ratio of 15:1 for healthcare costs and 2.4:1 in major diagnostic categories.Healthcare costs to health insurer and patient: Using a sample of 9,503 patients, Spetz, Parente, Town, and Bazarko (2013) used costs paid by the health insurer and costs paid by patients in their CMA.Looking at 10 commonly treated conditions, they compared costs accrued over a 14-day period after receiving treatment from an APRN practicing independently, an APRN with a limited scope of practice, or a PCP.Using regression models, estimated mean cost of care was less with APRNs providing the treatment.Spetz and associates estimated a savings of $810 million if states allowed APRNs to practice independently.The Perryman Group estimated Texas would see an annual impact of $24 billion in expenditures, $12 billion in gross product, and 122,735 permanent jobs by 2020; $34.8 billion in expenditures and $17.5 billion in gross product and 151,462 permanent jobs by 2030; and $46.9 billion in expenditures, $23.6 billion in gross product, and 177,220 permanent jobs by 2040, education costs were not included in the estimates NP Primary care Garner (2017) [46] Costs (4 studies): Non sig.differences in 3/4 ; trend to increased cost in ¼ studies related to initial hospital in-patient and day-patient hospitalizations.NP Primary care Jennings (2015) [103] Cost of soft tissue injury management was equal between medical, nurse practitioner and extended scope physiotherapist services (1/1) NP Primary Care Kuethe (2013) [85] Healthcare costs, direct and indirect Costs of outpatient visits were lower in the nurse-led group (outpatient visits costs per patient per year; €156 in the nurse-led group versus €189 in the physician-led group; P< 0.001), not statistically significantly to lower total costs in the healthcare sector (total health costs €343 in nurse led group versus €357 in physician-led group; P = 0.62).

NP Primary care
Leduc (2021) [93] Cost savings assessed in 5 studies; Three studies found lower costs per patient in the intervention group while two studies noted higher costs in the intervention group.stat sig not indicated NP Primary Care Lovink (2017) [34] Costs: sig.reduction in total costs in 1/1 study.Costs (3 studies): Non-significant reductions in costs noted in 2/3 studies.A significant reduction in health care costs in 1/3 studies (no p value reported)

NP Primary care
Morilla-Herrera (2016) [36]   Cost At 24 weeks after discharge, total Medicare reimbursements for health services were $1,238,928 in the control group vs $642,595 in the intervention group (P<.001)

APN Primary Care
Newhouse/ Stanik-Hutt (2013) [39][40] CNS: Four studies reported on costs.Studies were conducted in postpartum care, patients receiving end-of-life care, and guideline implementation for patients with radical prostatectomy.Equal to statistically significant reductions noted in costs when comparing CNS and non-CNS groups.

NP Primary Care
Sun (2022) [38]   Costs in home-based primary care (5 studies): Trends to cost savings noted in 2/5 studies with no p value reported.1/5 studies reported significant reductions in mean costs per patients in the post intervention year, No significant reductions at 2 years or mean day cost differences in 1/5 studies.One study reported on program costs.Cost savings of $200,000 for 18 participants but researchers did not report how they calculated savings in 1 study.Mean costs per patient in the postintervention year were significantly less in patients with high risk of hospitalization in the intervention arm than in those in the control arm ($5,088 vs. $6,575, p <.001) in 1 study.Total cost: No differences noted in at 2 years or per intervention year in 1 study, mean day-cost differences in 1 study Cost of NP intervention ($24,000 per 100 persons) and of preventing one day of stay in a nursing home ($35) estimated in one study published in 1995.

NP Primary Care
Swan (2015) [51] Cost of care (4 studies) 3/4 studies estimated cost using provider salary; of these, 2/3 found that APN care was less expensive compared with physician provided care.One study/4 examined annual laboratory and monthly medication costs; while APN care was less expensive for laboratory services (64.9 ± 34.5 versus 91.5 ± 36.7 euros, P = 0.001), there were no differences in monthly medication costs.Spitzer et al., 1976, examined cost of care by developing a Utilization and Financial Index in which provider salary was aggregated with laboratory, radiology, hospital costs and out of pocket expenditures; no differences were observed between care provided by APNs and physicians.NP Primary Care Tsiachristas (2015) [52] Cost of ANPs (5 studies): 2/5 showed reduced costs; 1/5 showed costs not sig.reduced; 2/5 showed that cost were increased

NP Primary Care
Yang (2021) [54] Wages (1 study): Change in NP hourly earnings compared with physicians before and after the expansion of NP scope of prescribing practice between 2005 and 2010.The researchers indicated that expanding prescribing authority increased NP hourly earnings yet decreased physician earnings Cost (price) of care (6 studies) Fewer restrictions of NP practice authority was associated with lower costs, more prescriptions filled in 5/6 studies CNS Acute Kilpatrick (2014)* [55] The incremental cost effectiveness ratio (ICER) was €3.61 less in direct costs (i.e.costs directly related to actions and decisions made by the CNS) but €20.34 more in overall costs (i.e.outpatient and inpatient costs for patient resource utilization in all related specialties) per quality adjusted life year (QALY) gained for the CNS intervention compared with usual care.Costs: the clinic visits were significantly higher than usual care; however, total health care costs did not differ significantly between groups.Fewer CNS patients received home help than inpatient controls and the CNS group had significantly lower treatment, health care and societal costs than both control groups.CNS Acute Bryant-Lukosius (2015)* [83] Costs were examined in 13 studies.There is no instance when resource use or costs were higher with CNS care but often instances when the CNS reduced resource use and costs, despite the fact CNSs represented an 'add-on' cost in these studies.

NP Primary Care
Martin-Misener (2015)* [69] Alternative provider nurse practitioner role in ambulatory primary care (4 non-inferiority trials): Nurse practitioners in alternative provider primary care roles could function at least at the level of physician comparators, with equal or lower costs in 4/4 studies Costs (2 studies) meta-analysis of the only two studies of this role that reported costs (2689 patients) with minimal heterogeneity and highquality evidence, nurse practitioner care compared to general practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros).All patient/provider outcomes in these studies were equivalent or better for the nurse practitioner.

Emergency Room Visits (18 reviews) APN Primary Care
Lawton (2018) [84] Emergency department attendance: no report CNS Acute Salamanca-Balen (2018) [126] Lower days in the ICU or E room visits showed non-significant changes between groups

APN Primary Care
Searle (2023) [133] ED visits: There were no significant difference for Emergency room transfers in 1/1 study.

NP Primary Care
McMenamin (2023) [47] Emergency room visits was examined in six studies with equal to statistically significant reductions noted in 6/6 studies.

NP Primary Care
Jeyaraman (2022) [104] Number of Emergency room visits with NP led triage (3 studies) Trends towards a decrease in Emergency room visits were noted in 2/3 studies (no p value reported).The number of patients visiting Emergency room increased by 51 visits per month compared to the traditional nurse-led triage mode in 1/3 studies.(no p value reported) A 5% decrease in Emergency room visits in the NP team triage group noted in 1/3 studies (no p value reported).The number of Emergency room visits preintervention dropped from 2194 Emergency room visits over 6 weeks to 1699 patient visits over one month during the postintervention period in 1/3 studies.(p value not reported).

NP Primary Care
Leduc (2021) [93] Emergency room Transports: Reduction in transport to hospital found in 10/10 studies with stat sig in 4/10.

NP Primary Care
Lovink (2017) [34] Emergency room visits not leading to hospitalization: Sig reduction in the intervention group in 1/1 study (P = 0.001).In LTC: Emergency room visit: sig decrease in 1/2 studies, (p = 0.006), no sig differences in ½ studies Primary HC: Number of visits to the emergency room : incidence rate ratio of 1.5 for the intervention group compared with the control group (P = 0.02) in 1/1

NP Primary Care
Osakwe (2020) [37] NP-home visits on Emergency room visits: sig 2/2.Significant reductions in the Emergency room visits by 35.56% and 23.7% after implementation of the home based primary care (HBPC) program after with 6 months (p = 0.001) and 12 months (p = 0.001) and home care patients who received NP-home visits had less Emergency room visits at 2 weeks (p = 0.0005) and 4 weeks (p = 0.0055) compared to those receiving usual care.No significant difference in the number of Emergency room visits between the 2 groups at the 8 week period (p = 0.800).

NP Primary Care
Sun (2022) [38]   Emergency room visits (8 studies) 5/8 reported significantly less Emergency room visits among intervention participants; no group difference in 3/8 studies

NP Primary Care
Martin-Misener (2015)* [69] Number of patients who had at least one emergency room or urgent care visit Nurse practitioner and general practitioner care were equivalent.Non sig.

Health Care Service Delivery (25 reviews) NP Primary Care
Baker (2017) [41] Use of health care resources examined in one study and low numbers of admissions in the three-month follow-up period made analysis unfeasible APN Primary Care Kennedy (2012) [92] Improved adherence to appointments: found in 1 qualitative study (Tough, 2006)  APN Acute Kobleder (2017) [78] Health service utilization was examined in one study with no group differences found between the intervention and control groups in relation to hospitalizations and office-based visits to oncologists.The same study found significantly more primary care visits for the control group and a trend towards more visits to the Emergency department in the intervention group.NP Primary Care Ansell (2017) [100] No Show rates: 4 studies.Unchanged ¼; reduction ranging from 1.44% to 5% in ¾ studies).No p-values reported.

NP Primary Care
Fung (2014) [45] Feasibility of transitional care model for patients with schizophrenia, not sig.(1/1) Home-based intervention for individuals with SMI/HIV, a significant improvement in depression (P = 0.012) and in the physical component of health-related quality of life (QOL) (P = 0.03) from baseline to 12 months.fewer primary care visits (β = −0.95± 0.16, P = 0.0003) for post-surgical women with ovarian cancers NP Primary Care Garner (2017) [46] Acceptability of nurse-led care assessed in 4 studies.Acceptability of nurse-led care superior in ¾ studies and unchanged in ¼ studies NP Primary Care HQO (2013) [62] Specialist visits: Model 1: more specialty visits at 12 months compared with 6 months in both groups; no differences at 12 months 1/1 Model 2: (no data) Primary care visits Model 1: mean number of visits 3.1 SD = 2.38, no sig differences between groups Model 2: (no data) NP Primary Care Jennings (2015) [103] Collaborative model of care: (1/1 study) increased patient throughput with larger numbers of patient presentations being seen

NP Primary Care
Kwok (2022) [99] Health services utilization: A meta-analysis was not performed due to significant heterogeneity in reported outcome measures including composite outcomes and differences in how outcomes were measured.Overall, there is no significant for reducing health service utilization.

NP Primary Care
Leduc (2021) [93] End of life care in 3 different ways between 5 studies One study implemented a palliative care framework and set of tools in addition to a palliative care nurse providing and modeling good palliative care.They report a 7% reduction in hospital admission in the last eight weeks of life.One author contributed three retrospective cohort studies to this review, one of which was a subgroup analysis of patients with moderate to severe advanced dementia.These studies evaluate palliative care consults provided by nurse practitioners that address goals of care and symptom management.All three studies showed a reduction in hospital admission in patients with palliative care consults, and both studies measuring ED visits found a reduction in these as well.Patients who had earlier consults had a hospital admission rate that was 13.2% less than those without consults (p=.003).

NP Primary Care
Lovink (2017) [34] Number of primary healthcare contacts: no sig differences.Difference is significant once outpatients contacts and primary care contacts are combined: 16.3 per patient in the intervention group vs. 24.3 per patient in the control group (P = 0.04) Process evaluation: no study was identified where implementation was an outcome measure in its own right

NP Primary Care
Morilla-Herrera (2016) [36]   Service use 1/2 studies At 180-days of follow-up, significant differences in the minutes/month spent by the community nurse between groups [34.5(102.0)vs 96.1 (352.2);P: 0.05]; 1/2 studies the intervention had no effect on overall service use rates at 30 or 120 days NP Primary Care Osakwe (2020) [37] Transition care and case management: half as many Emergency room visits compared with the usual care group (mean=0.50,SD=1.2 versus mean =0.99, SD=2.5;P = 0.096) (1 study).NP Primary Care Swan (2015) [51] Healthcare resource utilization (4 studies): Consultation length: Four studies examined consultation length.Three studies found that APN consultations were 3.0 [29] to 4.3 [33] minutes longer than those provided by physicians.Two RCTs and one follow-up study examined total number of primary care visits with conflicting findings at 1 year but fewer visits among APN patients at 2 years.One RCT and its follow-up study examined hospitalization and emergency room or urgent care visits with no significant differences between groups.

NP Primary Care
Tsiachristas (2015) [52] Health care utilization: Three studies 2/3 found no differences and one/3 study found an increase.

NP Primary Care
Van Vliet (2020) [53] Follow-up contacts (n= 1 study) Follow-up contact after the completion of prehospital EMS care also indicated no significant differences between PAs and nurses Resource use (n=1 study) One study found in 107 cases other EMS resources were released from the scene and put back in service while the NP attended the patient, (by default, two units respond to a call).Eighteen high utilizers of 911 were connected with a social work organization, and 12 of 18 (66.7%)decreased their use of EMS in the 90-days following.
NP Acute Veenema (2021) [122] Higher crude (uadjusted) resource use was noted in one study and one study showed similar resource use with the addition of the NPs.

NP Primary Care
Yang (2021) [54] NP growth over time (3 studies) 1 study reported that restricted practice regulations reduced NP growth rates by 25% over a 7 year period. 1 study showed no sig difference in practice authority and growth in rural communities over a 4-year period. 1 study showed that NP growth occurred across most states but that growth was significantly higher in states with reduced practice authority (prescribing) Overall health service utilization (n = 11) 10/11 studies reported higher services utilization under Full Practice Authority Primary care utilization included number of NP visits in primary care, routine check ups, rates of cancer screening, chronic disease management and preventable hospitalization, education, counselling, and medication-related visits, reduced use of the emergency, increase in number of psychotropic and opioid prescriptions with no decrease in mental health outcomes, increase in number of opioid misuse treatment admissions.No sig difference in State -level Opioid and benzodiazepine prescription rates with full prescriptive authority.
Usual care was superior in improving functional dependence, physical quality of life, depressive symptoms and symptom distress for patients with cancer.Health care delivery: Post-discharge care of patients with heart failure was reported in 3 studies, There was no instance where usual care performed significantly better than CNS care.CNS care reduced time to death or re-hospitalization and also reduced the combined end points of death or re-hospitalization, improved adherence to treatment recommendations and patient satisfaction and reduced costs and length of re-hospitalization stay.Healthcare delivery: Post-discharge care of elderly patients was reported in five studies.CNS transitional care was superior to usual care for time to re-hospitalization; total and multiple rehospitalizations; short, moderate and long-term re-hospitalizations and re-hospitalization length of stay as well as a number of cost outcomes (daily hospital costs, health services charges, total re-hospitalization costs and total reimbursement costs).
Health system outcomes were examined in two studies Of the 93 health system outcomes, CNS care was superior for 25 outcomes and equivalent for 68 outcomes.Post-discharge care of high-risk pregnant women and infants Three studies evaluated CNS transitional care for high-risk pregnant women and very low birthweight infants.CNS care performed better that usual care in all instances.CNS care was superior for two patient outcomes related to immunization of infants at 8 weeks and maternal satisfaction.NP Primary Care Donald (2015)* (transition) [33] Additional interventions (RR: 1.02, 95%CI: 0.66-1.56,p = 0.93) CNS Acute Kilpatrick (2014)* [55] Resource use was examined in five studies for CNSs in Complementary provider outpatient roles with equal resource use noted in 3/5 studies.Statistically significant increases in resource use noted in 2/5 studies in the intervention group where CNSs used significantly more resources because they made more referrals to mental health specialists and pre-natal visits.Intervention patients had more general medicine and mental health clinic visits than patients in the control group in one study.A t 24 months, there were no significant differences between groups in health resource use o r charges APN Acute Kilpatrick (2015)-Inpatients* [56] NP group: No significant differences noted in 2/2 studies for hospital length of stay, diagnostic tests, surgical procedures, hospital costs, consultations per patients, referrals to dietetics, total hospital charges, ancillary costs, pharmacy and radiology costs.Significant increase noted in received home care services received for patients discharged home in 1/1 study.

NP Primary Care
Martin-Misener (2015)* [69] Return visits: (3 studies) nurse practitioners were more likely to ask patients to return than the general practitioners (2562 patients; I2=76% (RR 1.32, 95% CI 1.20 to 1.46); p<0.0001).The number of patients who made return visits within 2 weeks for the index reason was reported in three trials.A meta-analysis, including almost 3500 patients (I2=5%), indicated that more nurse practitioner patients than general practitioner patients made return visits for the same problem or within 2 weeks (RR 1.18; 95% CI 1.06 to 1.32; p=0.002).
One study examined the number of return visits for any reason over 1 year and found equivalent results.

Hospitaliza�on (29 reviews) APN Acute
Allsop (2021) [10] Readmissions examined in 4 studies.One study reported a significant reduction in readmissions (p = 0.02) while another study noted a significant increase at 2 weeks post discharge (p<0.015).APN Acute Audet (2021) [7] Rehospitalization Equal to statistically significant reductions of re-hospitalizations in 5/5 studies APN Acute AND Primary Bohner (2012) [98] Rehospitalizations at 3-month, 6-month and 12-month periods were examined in four studies with equal to significant reductions noted in 4/4 studies for the intervention group.

APN Acute
Edkins (2014) [91] No significant difference was found between the 2 groups for ICU length of stay (LOS), readmission rates, NP Primary care Fichadiya (2021) [57] Differences in HF readmission rates were only significantly reduced with NP-led care after one year compared to usual care (p <.001); no significant differences were noted after two years APN Acute AND Primary Hyde (2020) [115] Readmission, return, and referral rates was examined in two studies and no significant differences were identified.:Return rates were higher in one study related to a confounder (presence of wheeze).Higher return rates in the APN group in 1/1 study // ICU activation: one study that examined ICU activation rates.This was used as a measure of organizational impact following introduction of a new model of APN care.The authors reported ICU activation rates had reduced from 100% pre-model to 50% then 64% post implementation APN Primary Care Lawton (2018) [84] Hospital admission: Data show a statistically higher proportion of hospital admissions in nurse-led care over the trial period.
APN Acute Ordonez-Piedra (2021) [95] hospital readmissions identified in nine studies with statistically significant reductions noted in all studies.

NP Primary Care
Osakwe (2020) [37] NP-home visits on hospitalizations: not sig. in 2/2 studies.The mean length of stay per hospitalization was 6.3 days in the intervention group and 5.1 days in the control group (p = 0.7) and p value in study 2: (p = 0.514).NP home-visits on readmission: 4 studies.2/4 studies reported significant decreases in hospital readmissions: for patient following cardiac surgery with the addition of home visits ( p = 0.023) in one A 59.42% decrease in readmissions at 6 months (p = 0.001) after enrollment in the home based primary care intervention led by a NP noted in another study, however the result was not sustained at the 12 month-interval (p = 0.087).Not sig findings in 2/4 studies.NP Primary Care Schadewaldt (2011) [67] No differences in hospital admissions at the 10 year follow up in one study NP Primary Care Smigorowsky (2020) [50] Effect of NP-led care on 30-day readmission rates for HF (2 studies) The meta-analysis using a model of random effects revealed NP-led care had no statistically difference (Risk Ratio: 0.74, 95% CI: 0.47, 1.17, Z = 1.27, p = .20)on 30-day readmission rates in HF.I2 statistic is 15% and indicates that at the risk of heterogeneity is low NP Primary Care Sun ( 2022) [38]   Hospitalization (12 studies) 10 /12 studies found that NP home visits led to significantly fewer hospitalizations.A trend of decreased hospitalizations noted in 2/12 studies with non-significant results.Nursing home admissions (3 studies) Fewer nursing home admissions in intervention groups in 3/3 studies.P values not all reported.
CNS Acute Kilpatrick (2014)* [55] Significantly shorter postpartum re-hospitalization length of stay, more prenatal visits, a nd lower prenatal hospital charges CNS Acute Bryant-Lukosius (2015)* [83] Data were combined from the two studies examining re-hospitalization at 6 months post-discharge and found no significant differences.

NP Primary Care
Martin-Misener (2015)* [69] Number of patients who were hospitalized at least once Nurse practitioner and general practitioner care were equivalent.Non sig.

Length of Stay (22 reviews) APN Primary Care
Chan ( 2018) [42] Hospital admission, length of stay and emergency presentation: Hospital admission, length of stay and emergency presentation were reported in nine studies.Equal to statistically significant improvements were noted in all studies.
APN Acute Allsop (2021) [10] Statistically significant improvements in LOS in 9/12 studies and improvements that were not statistically significant in 1/12 study APN Acute Audet (2021) [7] Hospital length of stay: Equal to statistically significant reductions in LOS n 2/2 studies APN Acute Curr ( 2015) [134] Emergency room length of stay was statistically shorter intervention groups in 3 studies and not significant in 1 study.

APN Acute
Edkins ( 2014) [91] No significant difference was found between the 2 groups for ICU length of stay, readmission rates,

APN Acute AND Primary
Hyde (2020) [115] Length of stay: no significant differences in length of stay in 2/3 studies, in the third study increased length of stay was attributed to higher acuity of patients seen by the APNs in the ICU.no significant differences in length of stay APN Acute Manoj (2019) [63] A statistically significant difference in length of stay results among three groups (MD group-4.6 hr, MD/NP group-4.2hr, NP group-3.7 hr) with a significantly shorter length of stay in the NP group (p <0.001).
APN Acute Medeiros (2011) [94] ICU length of stay: statistically significant reductions noted in 3/3 studies of NP care CNS Acute Salamanca-Balen ( 2018) [126] Equal to statistically significant reductions in LOS in 33 studies with two studies showing a statistically significant increase.
NP Acute Thamm (2019) [109] Length of stay in Emergency room: Equal to significantly shorter wait times noted in 4/4 studies.APN Acute Woo (2017) [96] Length of stay in Emergency room was reported in 4 studies with equal to statistically significant reductions noted in the NP-directed care model in 3/3 studies and similar results noted in collaborative care model in 1/1 study.Length of stay in critical care was reported in 7 studies with equal to statistically significant reduction noted in the NP directed care model in 3/3 studies and similar LOS noted on the collaborative care model in 4/4 studies.One out of four studies noted statistically significant reductions in patient transfers to other services, patient discharges to rehabilitation services, and time to discharge older patients on intravenous antibiotics/wound therapy.

NP Primary Care
Elder (2015) [86] Nurse-initiated X-Rays showed little impact on ED LOS in two studies/ 3. ED LOS: 1/1 indicated that ED LOS was not impacted by nurseinitiated analgesia.

NP Primary Care
Galiana-Camacho ( 2018) [87] Average length of stay per patient of 180 minutes, together with 78.5% of patients seen in less than 4 hours.

NP Primary
Care HQO (2013) [62] Length of stay: Model 2: no sig.difference in median LOS at 1 year (6 days, p= 0.49) (1/1) NP Primary Care Jeyaraman (2022) [104] Emergency roomlength of stay (LOS) (9 studies) All nine studies in the NP team triage model showed a decrease (median = -28.50minutes) in ED LOS favoring the intervention group.5/9 studies showed significant decrease in LOS and 4/9 indicated a decrease without reaching statistical significance.Patient discharge from ED within benchmark times (4 studies) At 60 minutes, 41% of patients discharged from the ED in the NP team triage vs 16% in the traditional nurse-led triage group (1/1 study) At 90 minutes, 30% of lowacuity patients in the NP team triage group discharged vs 12% in the traditional nurse-led triage group.(1/1 study) At 4 hours, 98.1% of patients discharged under 4 hours in the in the NP team triage group compared to 94.7% in the traditional nurse-led triage group.
( Postoperative complications, including infection, respiratory complications, and thromboembolism were measured in two randomized controlled trials.No significant association was identified for both randomized controlled trials.APN Acute Edkins (2014) [91] Urinary tract infection (UTI): lower rates of urinary tract infections when compared to routine medical management the previous year (p ˂ 0.05) Skin breakdown (p ˂ 0.05) significant reduction in 1/1 study when compared to routine medical management the previous year Significant increase in DVT identification in the NP group (4% vs 2.5%, P = 0.02) in 1/1 study because of increased compliance with aggressive screening guidelines in the organization.
CNS Acute Schoch (2014) [135] Time to occlusion of arteriovenous fistula (AVF): AVF access had the highest success rate in terms of survival in all three of their end point measurements in 1/1 study.
NP Acute Thamm (2019) [109] Adverse events were reported in four studies.No significant differences were noted in the number of readmissions, unplanned follow-up the initial consultation, mortality, missed fractures.

NP Primary care
Carranza (2021) [61] Treatment complications: 4/4 no sig difference between NP and physician groups Adverse effects 4/4 studies no sig difference between NP and physician groups NP Primary care Driscoll (2015) [90] Adverse events: (1 NP study) There were no differences in adverse events among groups.(1/1)

NP Primary Care
Galiana-Camacho (2018) [87] Medication and medical history: completed in 97.4% of patients encounters (1/1).Patient safety: Medication interaction: documented in 87.5% of cases (1/1).Sexual health: documented in 65.9% of cases (1/1).No unplanned readmissions by the Transitional Emergency Nurse Practitioner (TENP) were adequate (1/1).All diagnostic tests requested by the Transitional Emergency Nurse Practitioner (TENP) were adequate (1/1).NP Primary Care Garner (2017) [46] Adherence to lab tests: no stat.sig.difference between nurse-led care and rheumatologist-led care in 4/4 studies for: mandatory monitoring of laboratories for patients; out-of-range blood tests.Hospitalizations: the number of hospitalizations 5/5 no sig.difference in nurse-led care; number of unplanned family physician visits: no diff.at 12 months and 24 months (1/1) Safety: Adherence to lab tests: no stat.sig.difference between nurse-led care and rheumatologist-led care in 4/4 studies for: mandatory monitoring of laboratories for patients; out-of-range blood tests.

NP Primary Care
HQO (2013) [62] Risk factor management Model 2: CAD patients receiving care from specialized nurses were 5 times more likely to achieve appropriate blood pressure (P <0.001) management and 3 times more likely to have appropriate lipid management (P <0.001) (1/1)

McParland
Falls (1 study): Case-finding for referral to other services did not reduce falls risk.(p value not reported)

NP Primary care
Morilla-Herrera (2016) [36]   Falls rate: 1/2 studies showed significant reduction in falls (p = 0.003); ½ studies found no significant differences in the number of falls

APN Primary Care
Newhouse/ Stanik-Hutt (2013) [39][40] CNS: Complications.Three studies reported patient complications.Studies were conducted with patients discharged following a stroke or transient ischemic attack, receiving care in a surgical intensive care unit, post-operative cardiac surgery, and a pregnancy wellness program.Equal to statistically significant reduction in complications noted in 3/3 studies when comparing CNS and non-CNS groups.

NP Primary Care
Yang (2021) [54] Malpractice (1 study) Between 1999 and 2012: 31% lower malpractice payments per 1,000 physicians in states with FPA compared with those with restricted practice authority CNS Acute Kilpatrick (2014)* [55] Health system outcomes, restraint reduction did not increase staff hours.
APN Acute Kilpatrick (2015)-Inpatients* [56] CNS group: Patient safety: no significant differences in the number of sitter walk-aways or adverse patient events between suicidal and non-suicidal patients

NP Primary Care
Harkless (2018) [139] State-determined Medicaid reimbursement and scope of practice legislation shapes nurse practitioner clinical practice.With full scope of practice authority and Medicaid reimbursement at 100% of the physician's rate, more NPs work in primary care, a higher number of practices employing NPs accept Medicaid, and primary care practices with NPs are more likely to be located in rural and high poverty areas.When Nurse practitioners are identified primary care providers there is discrepancy of payment by insurance providers : The factors may include local policies at the NP's employment site or their parent health system, state laws and regulations that do or do not require the recognition of NPs as primary care providers.Managed care organizations (MCOs) do not have consistent standards for who is or is not a recognized as a primary care provider contracted to provide care to a panel of patients.Instead, the provider credentialing process used by MCOs, along with subsequent contracting standards, vary between and within states, with the percent of MCOs credentialing NPs stable at 74% in 2012 and 75% in 2016.Reimbursement parity is not the same for NPs: Legislated policy barriers, as well as disadvantageous third-party insurer policies, create financial sustainability issues for NP-managed clinics.Reimbursement was singled out as a key consideration and barrier affecting sustainability of both nurse-managed clinics and NP private practice.Incident to billing -practices still bill under a physician rather than an NP to receive full payment.Very limited data are available on the process and outcome of credentialing and contracting for reimbursement of NPs by location, setting, or specialty.
CNS Primary Hourahane (2012) [140] The 11 synthesized findings pertain to a list of factors that facilitate and inhibit consultant nurse (CN) role implementation and development: 1.Four role functions: The CN needs to engage in all four role functions to facilitate role development, working across different areas with patients and at a strategic level with appropriate time management and an integrated approach are also necessary.Not working with patients and at a strategic level also hinders the CN's role development.Difficulty in demonstrating their impact in changing culture, service and practice development also impede role development.2. Ability to influence through leadership and vision.
3.Organisational structure with autonomy allowing the CN to make major decisions.4. Good working relationships with key individuals, supported by supervision and regular meetings, facilitate the CN role. 5. CN receiving administration and managerial support from the organisation.6.Role clarity Managers and other members of the team also need to have a clear understanding of the CN role and be able to differentiate it from other nursing roles.7. Role development: The consultant nurse's previous experience of developing a role with clear business and succession planning which is supported by the organisation (particularly in providing secretarial support).Time in the post, confidence and workload management also facilitate the crafting of the role which moves in cycles rather than in a linear way over a period from 18 months up to 5 years.8. Role preparation should include induction; education to master's level with a variety of educational experiences including a broad preparation and structured approach which may use a medical model.Ongoing engagement and support for continuous professional development and research is essential.9. Personal attributes include the ability to lead change, empower others in exercising leadership using a determined yet collaborative approach.Other essential attributes are self-confidence, motivation, credibility and commitment.10. Kennedy (2012) [92] Development of other staff because of work of nurse consultant found in 9 qualitative studies Detriment to other staff because of work of nurse consultant found in 2 qualitative studies and in 1 quantitative study (1 survey question on deskilling of doctor experience/role -added comment "for most part not an issue").Delay in decision to wean found in 1 quantitative study.Development of networks, services, improved/activated policies found in 8 qualitative studies .Improved standards of care found in 5 qualitative studies.Clinical Social significance: was captured in outcomes related to reduced mortality, waiting times and service/appointment utilization.From a broad perspective this was also suggested qualitatively, for example developing services, improving care, reducing waiting times Professional social significance was related to consultants in the professional social significance category, such as contributing to role extension, the development of new nursing roles recruitment and retention, reducing others' workload and contributing to meeting the education needs of staff.Professional social validity, several qualitative studies indicated that staff valued nurse consultants' contribution and three surveys illustrated the usefulness of nurse consultant-led services amongst GPs and nursing staff APN Acute Lyness (2021) [130] A clearly defined skillset, scope of practice and role: Some out-of-hours services appeared to expect non-medical practitioners NMPs to function as GPs, although they do not have the same breadth and depth of knowledge and skills.Therefore, it is not surprising that they felt unprepared for certain patients and sometimes avoided them NP Acute AND Primary Niezen ( 2014) [107] The organizational environment imposes a set of factors, located outside the professional communities of physicians and NPs, which influences the successful implementation of NPs in a healthcare setting.In total, eight subcategories were defined: (1) organizational policy support, (2) complexity of cure and care provided, (3) facility arrangements, (4) employment arrangements, (5) institution's familiarity with the (regulatory) environment ( 6) type of health setting, (7) experience in working with NPs, and (8) (inter)professional collegiality.The first factor, organizational policy support, was addressed in eight studies, and encompasses a demarcation of the NP's role, that professional tensions are addressed, that protocols or formal procedures are available and that unwarranted restrictions, such as limited prescription authority, are removed.Four studies indicate that the complexity of the cure and care provided is an important factor in the acceptance of NPs as cure providers.The less complex the cure component (medicine), the more positive the attitude towards NPs fulfilling these tasks.Both facility and employment arrangements influence the ability of NPs to perform their role.The lack of proper facility arrangements, such as not having one's own office/treatment space and computer, was experienced as a barrier to task reallocation.Like facility arrangements, employment arrangements can limit or enhance the full integration of NPs into a team or clinical practice.Other factors within the organizational environment that can facilitate/hinder task substitution are: the health setting's familiarity with (governmental) regulations and rules , the type of health setting , the amount of (previous) experience with NPs , and (inter)professional collegiality .Institutions need to know how (the interaction between) regulations and rules can either facilitate or hinder the roles and functions of NPs.The type of health setting focuses on the difference between, for example, a community clinic and a hospital; the former being less supportive of expanding the scope of nursing practice roles to the domain of medicine than the latter, as it has different expectations and often less experience with NPs .(Inter)professional collegiality refers to the perceived support from within the nursing professions, the support, effort and trust from management and the enthusiasm from other people involved [1].Institutional environment entails the influences of legal, political and societal institutions in shaping the healthcare system.These external factors can have a strong impact since they involve: (1) legislation, (2) socioeconomic forces, (3) governmental (research) policy, and (4) patients' perceptions.Legislation is referred to as a barrier by six studies.The socio-economic forces shaping NP care are reported in seven studies NP Acute Veenema (2021) [122] Fifteen studies attempted to determine the number of NPs in Emergency rooms.National surveys found a growing number of Emergency rooms staffed with NPs.One study noted that NPs account for 5% of independent billing in this setting.Workforce data often included physician assistant roles.Seven studies examined whether NPs could care for patients independently.In one study, patients were discharged by the NP more frequently directly following triage.

NP Primary Care
Patel (2019) [108] NP SOP and characteristics of the health delivery system: 8 studies more growth in the number of NPs in states with the least restrictive SOP policies.Patients in states with the least restrictive NP SOP policies were more likely to have an NP as their PC provider.The results of most studies showed a positive association between less restrictive NP SOP policy and NP workforce capacity.1/8 study reported no significant association between NP SOP policy and number of NPs licensed to practice per 100,000 population.NP SOP and characteristics of the population-at-risk: 5 studies.4/5 studies reported that NPs with less restrictive Scope of practice were more likely to work in PC, provide care in rural and high-poverty areas.Accept patients under Medicaid; sig difference in 2/5.One study found no sig difference NP SOP and utilization of health services: 4 studies greater use of preventive services and decreased rates of avoidable hospitalizations, hospital readmissions within 30 days discharge from rehabilitation, and hospitalizations of nursing home patients in states with the least restrictive NP SOP policies in ¾ studies One out of the four studies reported an increased likelihood of patients receiving a referral to a physician from an NP at Community Health Centers in states with SOP policies that allow NPs to practice without physician supervision.¼ studies reported that a larger supply of NPs, without considering other state-and patientlevel factors, did not significantly affect healthcare utilization.NP Primary Care Yang (2021) [54] NP Supply (6 studies): 5/6 studies showed a positive association between FPA and NP supply.1/6 (nursing home study), reported an insignificant relationship (Intrator et al., 2015).NP Workforce distribution.(4 studies) 1/3 studies indicate higher odds of NPs in rural areas in states with FPA, compared with those with restricted regulations, though the difference was not statistically significant 2/3 studies found significantly greater numbers of NPs in rural areas of states with FPA than those with restricted practice regulations 1/1 study evaluating the odds of NPs practicing primary versus specialty care by level of state NP practice regulations and found that NPs had 13% higher odds of practicing primary care in states with FPA than in states without it NP autonomy (2 studies).NPs had greater day-to-day practice autonomy when they had full independent prescriptive authority, yet having practice independence for diagnosis and treatment only showed little effect on autonomy.2/2 studies: no difference in NP hospital admission privileges by level of state NP practice regulations and hospital admission privileges did not differ by prescriptive or practice independence.
Mobility (1 study) odds of moving from one state to another by state NP practice regulations between 1992 and 2004 and found that NPs were 46% more likely to move from a state with no controlled substance prescriptive authority to one that allows NPs to prescribe them.NP-provided health service use (5 studies) Full practice authority led to sig increases in care provided by NPs in 4/5 studies.Neg association in 1/5 studies (services provided in LTC) APN Acute Ramis (2013) [145] Advanced practice registered nurses working in roles within acute, hospital, or tertiary care centre, intensive care and critical care units as well as hospital emergency departments.Six themes were identified in the study.1) Expert knowledge: Outcomes to patient, provider and healthcare system-APNs have expert knowledge that is required, utilized and is ongoing.Outcomes to education-APNs are an educational resource for their departments and spend a large amount of time educating peers, staff, patients and their families.2) Spectrum of work activities: Outcomes to provider and healthcare system-APNs experience a certain amount of routine in their daily work; APNs work in diverse areas with varying management responsibilities and functions.They may work independently or interdependently 3) Confidence and familiarity: Outcomes to provider-APNs exhibit familiarity with tasks and have the ability to use their previous experience to deal with varied issues; APNs demonstrate intuitive knowledge in their practice.Outcomes to patient and healthcare system-confidence in their role allows APNs to make quick and effective decisions, time manage, prioritize and bypass hierarchy if required; APNs have a strong sense of responsibility and accountability 4) Negative experiences: Outcomes to patient, provider and healthcare system-having to do a large component of administrative work detracts APNs from patient care and contributes to overtime, work overload and frustration; organizational factors can affect APN experiences and service utilization.Outcomes to provider-negative experiences with staff relationships, organization and workload can impact greatly on the APN experience at a personal and professional level 5) Relationships: Outcomes to patient, provider and healthcare system-multi-disciplinary relationship building and maintaining positive relationships are essential components of the APN experience.Outcomes to patients, healthcare system and education-APNs demonstrate expert communication skills in their professional relationships as well as patient and staff interactions; consultancy and liaison can be extensive and may link the APNs unit to other internal departments and at times, areas external to the hospital environment.Outcomes to patient, provider, healthcare system and education-acting in a professional manner in all circumstances is paramount to the APN experience.6) Patient-centered experiences: Outcomes to patients-the patient is central to the APN experience.Outcomes to patients, provider, healthcare system and education-APNs provide support to staff, patients, families and each other; APNs have positive and rewarding experiences which are usually related to positive patient care experiences APN Acute AND Primary Jokiniemi (2012) [146] The goal of the position is to help provide better outcomes for patients improving services and quality, to strengthen leadership, and to provide a new career opportunity to help retain experienced and expert nurses in practice.Each position should be structured around four core functions of expert practice, professional leadership and consultancy; education, training, and development; and practice and service development, and research and evaluation.The position should involve working directly with patients, clients, or communities for at least 50% of the time available.
In the USA, the role of the CNS dates back to the early 1940s.The American Nurses Association defines the CNS as "an advanced practice nurse who integrates and applies a wide range of theoretical and evidence-based knowledge and is licensed, certified and/or approved to practice.Wait Times (12 reviews) APN Acute Allsop (2021) [10] Time to surgery was reported in seven studies.Trends toward reductions to statistically significant reductions reported for time to surgery and improvement in the number of patients having surgery within 24 hours APN Acute Manoj (2019) [63] Wait times were not reported in retained studies with APNs NP Acute Veenema (2021) [122] Wait times were reduced in two out of two studies.

APN Primary Care
Whiteford (2016) [111] Waiting time reported in one study with considerable reductions noted (no p value reported) APN Acute Woo (2017) [96] Wait time in the Emergency Department was examined in five studies with equal to statistically significant reductions noted in the intervention group for time to consultation in 4/4 studies.Statistically significant reductions in time to treatment were noted in 1/1 study where a greater proportion of patients (15.4%) managed by emergency NPs received analgesia within 30 min of arrival at the ED compared to patients managed by physicians (1.6%) (P <0.001).Wait time in critical care was examined in one study with statistically significant reductions in time to treatment for patients with acute ischemic stroke (P <0.001).

NP Primary Care
Ansell (2017) [100] [61] Wait times was reported in 2 studies.Decreased wait time from 46 to 42 days for non-urgent appointments in pediatric NP clinic; no pvalues reported (2/2).NP Primary Care Elder (2015) [86] Did-Not-Wait rate was reported in one study with a 1% reduction in Did-Not-Wait (DNW) rates over a 12 month period following the introduction of the clinical initiative nurses (CIN) role (P <0.001).(1/1) Nurse-initiated X-Rays showed little impact on wait times in two studies/ 3. Wait times: Reduced in 5/6 studies 1/1 study) Under 6 hours, 85.7% of patients discharged in the NP team triage group vs 80.1% in the traditional nurse-led triage group.(1/1 study) Time to triage (2 studies) Statistically significant decrease (pre-intervention time to triage (Median: 4; IQR: (2, 10)); post-intervention time to triage (Median: 3; IQR: (1, 8)) favoring the intervention group noted in ½ studies.98% of patients in the intervention group were triaged within 15 minutes vs 75% of patients in the comparison group.(p value not reported) Work overload: Achieving a good work life balance and managing increased workload each facilitate role development.11.What the CN role gives the CN: The role labelled as the CN gives the CN higher status, facilitates clinical credibility and enables professional development.In addition, having a clinical caseload and involvement in clinical care maintains that credibility.
Wait times for appointments: reduced wait times in 11/11 studies.Mean reduction of -11.3 days (SD +/-8.3 days) for all included studies after implementation.Open access scheduling: Reduced wait times in 11/11 studies.No p-values reported.Wait times for appointments: Use of NPs reduced wait times for appointments in 2/2 studies.No p-values reported.Telephone follow-up consultations reduced wait times for appointments in 2/2 studies.No p-values reported.Measures to promote self care reduced wait times for appointments in 2/2 studies.No p-values reported.Email consultations reduced wait times for appointments in 2/2 studies.No p-values reported.